Go Around Decision Making

Transcription

1 Bill Curtis Project Co-Chair I acknowledge receipt of your message and attached file. Thank you very much. Kind regards, Go Around Decision Making FLIGHT SAFETY FOUNDATION 1

2 The Issue Ineffective Go-Around Policies 2

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4 Distilled down Aircraft Accidents APPR & LND Everything Else 4

5 So how do we fix this? Eliminate unstable approaches But is it the best strategy?

6 FSF ALA Study [SMS, Oregon] Runway Landing Excursions 53% Veer Offs: (277) [wind 40%] [cont. 39%] 66% Stable approach 44% Unstable approach 47% Overruns: (243) 37% Stable approach 63% Unstable approach 52% Stable Approaches 48% Unstable Approaches

7 How are we doing at preventing unstable approaches? % unstable - Airbus study 3.4 % unstable - LOSA study very good can we do better? Stable Unstable

8 What is the compliance rate of executing go around policies? 83% of all ALAs preventable with a go around [Jim Burin, IASS 2011] 3% compliance - Airbus study 4% compliance - LOSA 3% compliance - ASIAS analysis no other single decision can have such an impact on the industry accident rate [Curtis 2007]

9 Let s look at this another way Go Around Policies 9

10 Recap: 65+% of industry accidents are ALAs 83% of all approach and landing accidents are preventable with a go- around [Jim Burin, FSF/IASS 2011]. 65% x 83% 54%industry accidents could be prevented with a decision to go-around The go-around rate is less than 1 in 30 Little data to explain why Why has the industry not been interested in this?

11 What Makes an Effective Policy? Go Around Policy Execute the Policy - accomplished by Flight Crews Management of the Policy - Managed by managers Guidance - is trusted/believed in

12 The Research 12

13 Ability to predict compliance (logistic regression model): Predictor Variables Flight Instability Factors (fight path deviation, Vref+ 20, +1000ft/min sink rate, etc.) Predictive Accuracy of Go- Around Decision 60% Environment Factors (weather, winds, runway conditions, ATC late vectoring, etc.) 61% Psychological Drivers for Non-compliance 86%

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16 Significant Findings Psychology of Systemic and Chronic Non Compliance Unstable Approach (UA) pilots scored significantly lower on all SA components UA pilots communicate less in the flight deck UA pilots are more tolerant of missing, and less complaint in making, standard calls and checklist items Pilots feel go-around criteria is unrealistic Pilots feel there is no disincentive to not comply, i.e. management is not concerned UA pilots feel discomfort in challenging other crew members, particularly with a steep authority gradient in flight deck GA pilots reported by more than 4 times than UA pilots that someone in the flight deck prompted a go-around

17 Significant Findings Psychology of Systemic and Chronic Non Compliance Management is disengaged from the issue and unaware of the risks and impact on accident rates 68% of managers did not know the rate of compliance in the industry, 16% estimated a rate close to the actual rate of 3% 55% did not know their company s rate of compliance, 12% estimated their companies compliance rates as being <10% 31% of respondents were dissatisfied with their company s rate 20% saw their policies as ineffective Managers scored low on all SA components Of those who scored higher, they see their policies as unrealistic and definitions too narrow

18 Significant Findings Psychology of Systemic and Chronic Non Compliance Managers perceive below a moderate level of support to manage GA non compliance, and little desire from senior management for change The industry tendency is to correct approach and landing accidents by a single focus on minimizing unstable approaches Safe landing guidelines, e.g. FSF guidelines, are not well known or published

19 Key Recommendations 1. Enhance awareness of go-around policy non-compliance (GANC), rates, and significant impact it has on accidents rates Industry establish an identifiable label that relates to go-around non-compliance, similar to CFIT, or LOC Develop industry and operator communication initiatives Annually track industry GANC rates 1. Minimize the subjectivity of the go-around decision Install and train stable approach and energy management monitoring and alerting systems Manufacturers continue to develop stable approach and energy management monitoring and alerting systems Operators establish standard communication calls that; Are active (vs passive for every approach) Create shared responsibility for a stable approach Continue and escalate when unstable conditions remain Go deep into the approach and/or landing

20 5. Operators include Safe Landing Guidelines in operating manuals and go-around policies Key Recommendations 3. Set go-around compliance rate targets and monitoring programs Operators set GANC rate targets, and management processes to mitigate State and industry audit programs include GANC standards and recommended practices 4. Optimize the stable approach definition and go-around policies to improve relevancy for flight crews and management Re-define heights and criteria to exclude very low risk Separate profile heights and energy management criteria heights Separate stable approach definitions from decision point definitions Allow for variable objective environments Allow room for non-prescriptive, but guided decision making

21 Let us look at a simple example of a change in just one variable

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23 % of Unstable Approaches Continued to landing Revised GA Policy Better Managemen t of Policy Mitigation Improved Decision-Making

24 Crosswind Landing Video - Dusseldorf

25 Thank You 25